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Pediatric Department University of Verona Italy Giorgio Piacentini

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Page 1: Pediatric Department University of Verona Italy Giorgio Piacentini

Pediatric DepartmentUniversity of Verona Italy

Giorgio Piacentini

Page 2: Pediatric Department University of Verona Italy Giorgio Piacentini
Page 3: Pediatric Department University of Verona Italy Giorgio Piacentini

Patterns of Allergic Reactivity and Disease in Olympic Athletes

Katelaris: Clin J Sport Med 2006;16:401

A survey case series of Australian Olympic and Paralympic athletes.

A questionnaire seeking information on the presenceof allergic disorders, symptoms, family history, and medication use was administered.

Skin-prick tests (SPT) for sensitivity to common aeroallergens was performed.

977 athletes (725 Olympic, 252 Paralympic) from 34 different sports

Presence of Asthma and Sporting Category

Indoor vs outdoor

0 1 2 3

Aquatic vs nonaquatic

Endurance vs others

Swimmers vs nonswimmers

O.R.

1.5; p<0.01

1.5; p<0.007

1.4; p<0.03

2.5; p<0.001

Page 4: Pediatric Department University of Verona Italy Giorgio Piacentini

Patterns of Allergic Reactivity and Disease in Olympic Athletes

Katelaris: Clin J Sport Med 2006;16:401

A survey case series of Australian Olympic and Paralympic athletes.

A questionnaire seeking information on the presenceof allergic disorders, symptoms, family history, and medication use was administered.

Skin-prick tests (SPT) for sensitivity to common aeroallergens was performed.

977 athletes (725 Olympic, 252 Paralympic) from 34 different sports

Presence of Asthma and Sporting Category

Indoor vs outdoor

0 1 2 3

Aquatic vs nonaquatic

Endurance vs others

Swimmers vs nonswimmers

O.R.

1.5; p<0.01

1.5; p<0.007

1.4; p<0.03

2.5; p<0.001

Swimmers were more likely to be atopic and to have allergic symptoms than other sporting groups

Page 5: Pediatric Department University of Verona Italy Giorgio Piacentini
Page 6: Pediatric Department University of Verona Italy Giorgio Piacentini

"Coughing water": bronchial hyperreactivity induced by swimming in a chlorinated pool.

Mustchin: Thorax. 1979;34:682

Indoor swimming pools, water chlorination and respiratory health Nemery:Eur Respir J 2002; 19:790

“chlorination may affect the respiratory health of either those who work as swimming attendants or instructors, or those who use the pools as customers, particularly children and the general public, but also competitive swimmers”.

Page 7: Pediatric Department University of Verona Italy Giorgio Piacentini

Increased sensitization to aeroallergens in competitive swimmers.

Szwick: Lung. 1990;168:111

14 competitive swimmers 14 matched control subjects

clinically manifest allergies,

subclinical sensitization to aeroallergens,

BHR to Mch.

11

3

9

4

11

5

Conjunctival or respiratory

symptoms

Sensitization to

aeroallergens

BHR to

Mch

Page 8: Pediatric Department University of Verona Italy Giorgio Piacentini

Increased sensitization to aeroallergens in competitive swimmers.

Szwick: Lung. 1990;168:111

14 competitive swimmers 14 matched control subjects

clinically manifest allergies,

subclinical sensitization to aeroallergens,

BHR to Mch.

11

3

9

4

11

5

Conjunctival or respiratory

symptoms

Sensitization to

aeroallergens

BHR to

Mch

This higher incidence of allergic diseases and subclinical sensitization to aeroallergens and bronchial hyperresponsiveness in competitive swimmers compared with control subjects could be due to repeated exposure to chlorine in swimming pools

Page 9: Pediatric Department University of Verona Italy Giorgio Piacentini

Exposure to trichloramine and respiratory symptoms in indoor swimming pool workers

Jacobs: Eur Respir J 2007; 29: 690–698

624 pool workers

38 swimming facilities

Chloramine levels were measured by area sampling over 2-h periods and analysed using ion chromatography

Work-related and general respiratory symptoms, and symptoms indicative of atopy and BHRwere considered.

Respiratory symptom prevalence among pool workers was compared with symptoms in a Dutch population sample

100 –

80 –

60 –

40 –

20 –

0

76%

11% 5%NaClO

<3%

by salt electrolysis

NaClO Combined O3 +NaClO

Method for water disinfection%

Page 10: Pediatric Department University of Verona Italy Giorgio Piacentini

Exposure to trichloramine and respiratory symptoms in indoor swimming pool workers

Jacobs: Eur Respir J 2007; 29: 690–698

624 pool workers

38 swimming facilities

Chloramine levels were measured by area sampling over 2-h periods and analysed using ion chromatography

Work-related and general respiratory symptoms, and symptoms indicative of atopy and BHRwere considered.

Respiratory symptom prevalence among pool workers was compared with symptoms in a Dutch population sample

Sw

imm

ing

in

stru

cto

rs

Sinusitis

Chronic cold

Sore throat

Blocked nose

Cough

Phlegm

0 1 2 3 4

2.4

3.4

2.4

2.4

2.0

2.6

Page 11: Pediatric Department University of Verona Italy Giorgio Piacentini

Exposure to trichloramine and respiratory symptoms in indoor swimming pool workers

Jacobs: Eur Respir J 2007; 29: 690–698

624 pool workers

38 swimming facilities

Chloramine levels were measured by area sampling over 2-h periods and analysed using ion chromatography

Work-related and general respiratory symptoms, and symptoms indicative of atopy and BHRwere considered.

Respiratory symptom prevalence among pool workers was compared with symptoms in a Dutch population sample

Sw

imm

ing

in

stru

cto

rs

Sinusitis

Chronic cold

Sore throat

Blocked nose

Cough

Phlegm

0 1 2 3 4

2.4

3.4

2.4

2.4

2.0

2.6

po

ol

atte

nd

ants

0.7

1.4

2.0

1.2

2.3

2.0

Page 12: Pediatric Department University of Verona Italy Giorgio Piacentini

Exposure to trichloramine and respiratory symptoms in indoor swimming pool workers

Jacobs: Eur Respir J 2007; 29: 690–698

624 pool workers

38 swimming facilities

Chloramine levels were measured by area sampling over 2-h periods and analysed using ion chromatography

Work-related and general respiratory symptoms, and symptoms indicative of atopy and BHRwere considered.

Respiratory symptom prevalence among pool workers was compared with symptoms in a Dutch population sample

Sw

imm

ing

in

stru

cto

rs

Sinusitis

Chronic cold

Sore throat

Blocked nose

Cough

Phlegm

0 1 2 3 4

2.4

3.4

2.4

2.4

2.0

2.6

po

ol

atte

nd

ants

0.7

1.4

2.0

1.2

2.3

2.0

com

bin

ed t

he

job

s o

f p

oo

l at

ten

dan

t an

d i

nst

ruct

or

3.7

3.5

3.2

3.0

1.9

Page 13: Pediatric Department University of Verona Italy Giorgio Piacentini

Exposure to trichloramine and respiratory symptoms in indoor swimming pool workers

Jacobs: Eur Respir J 2007; 29: 690–698

624 pool workers

38 swimming facilities

Chloramine levels were measured by area sampling over 2-h periods and analysed using ion chromatography

Work-related and general respiratory symptoms, and symptoms indicative of atopy and BHRwere considered.

Respiratory symptom prevalence among pool workers was compared with symptoms in a Dutch population sample

Sw

imm

ing

inst

ruct

ors

Sinusitis

Chronic cold

Sore throat

Blocked nose

Cough

Phlegm

0 1 2 3 4

2.4

3.4

2.4

2.4

2.0

2.6

pool

att

enda

nts

0.7

1.4

2.0

1.2

2.3

2.0

com

bine

d th

e jo

bs

of p

ool a

tten

dant

an

d in

stru

ctor

3.7

3.5

3.2

3.0

1.9

An excess risk for respiratory symptoms indicative of asthma was observed in swimming pool employees. Aggravation of existing respiratory disease or interactions between irritants and allergen exposures are the most likely explanations for the observed associations.

Page 14: Pediatric Department University of Verona Italy Giorgio Piacentini
Page 15: Pediatric Department University of Verona Italy Giorgio Piacentini

Ecological association between childhood asthma andavailability of indoor chlorinated

swimming pools in EuropeNickmilder: Occup Environ Med 2007;64:37

Relationships between the prevalences of wheezing as reported by the International Study of Asthma and Allergiesin Childhood (ISAAC) and the number of indoor chlorinated swimming pools per inhabitant in the studied centres

Number of indoor chlorinated swimming pools per 100 000 inhabitants

Pre

vale

nce

of e

ver

asth

ma

(%)

Page 16: Pediatric Department University of Verona Italy Giorgio Piacentini

Ecological association between childhood asthma andavailability of indoor chlorinated

swimming pools in EuropeNickmilder: Occup Environ Med 2007;64:37

Relationships between the prevalences of wheezing as reported by the International Study of Asthma and Allergiesin Childhood (ISAAC) and the number of indoor chlorinated swimming pools per inhabitant in the studied centres

Number of indoor chlorinated swimming pools per 100 000 inhabitants

Pre

vale

nce

of e

ver

asth

ma

(%)

Page 17: Pediatric Department University of Verona Italy Giorgio Piacentini

Ecological association between childhood asthma andavailability of indoor chlorinated

swimming pools in EuropeNickmilder: Occup Environ Med 2007;64:37

Relationships between the prevalences of wheezing as reported by the International Study of Asthma and Allergiesin Childhood (ISAAC) and the number of indoor chlorinated swimming pools per inhabitant in the studied centres

Number of indoor chlorinated swimming pools per 100 000 inhabitants

Pre

vale

nce

of e

ver

asth

ma

(%)

Page 18: Pediatric Department University of Verona Italy Giorgio Piacentini

Ecological association between childhood asthma andavailability of indoor chlorinated

swimming pools in EuropeNickmilder: Occup Environ Med 2007;64:37

Relationships between the prevalences of wheezing as reported by the International Study of Asthma and Allergiesin Childhood (ISAAC) and the number of indoor chlorinated swimming pools per inhabitant in the studied centres

Number of indoor chlorinated swimming pools per 100 000 inhabitants

Pre

vale

nce

of e

ver

asth

ma

(%)The difference in pool

Ventilation according to the climate might explain why the relationships between asthma and pool availability appear steeper in Northern Europe compared to Southern Europe.

Page 19: Pediatric Department University of Verona Italy Giorgio Piacentini

Ecological association between childhood asthma andavailability of indoor chlorinated

swimming pools in EuropeNickmilder: Occup Environ Med 2007;64:37

Relationships between the prevalences of wheezing as reported by the International Study of Asthma and Allergiesin Childhood (ISAAC) and the number of indoor chlorinated swimming pools per inhabitant in the studied centres

Number of indoor chlorinated swimming pools per 100 000 inhabitants

Pre

vale

nce

of e

ver

asth

ma

(%)

The prevalences of childhood asthma and the number of indoor chlorinated swimming pools in Europe are linked.

‘‘Pool chlorine’’ hypothesis: the rise of childhood asthma could result, at least partly, from the increasing exposure of young children to chlorination products in the air and water of indoor swimming pools

Attendance at chlorinated swimming pools should be included among possible risk factors of childhood asthma and allergy

A need to evaluate the long term respiratory effects of chlorination products that children inhale in swimming pools

A need to regulate the concentrations of this irritant and to ensure that indoor swimming pools are properly ventilated

Page 20: Pediatric Department University of Verona Italy Giorgio Piacentini

Chlorine-induced Injury to the Airways in MiceMartin: AJRCCM 2003; 168:568–574

Exposure to Cl2 gas

occupational asthma

?induction of

airway inflammationand AHR

by oxidative damage

24 hours after a 5-minute exposure to 100 200 400 800

MCH assessed

ppm Cl2

2 and 7 days after 400 ppm Cl2

Page 21: Pediatric Department University of Verona Italy Giorgio Piacentini

Chlorine-induced Injury to the Airways in MiceMartin: AJRCCM 2003; 168:568–574

Exposure to Cl2 gas

occupational asthma

?induction of

airway inflammationand AHR

by oxidative damage

24 hours after a 5-minute exposure to 100 200 400 800

MCH assessed

ppm Cl2

2 and 7 days after 400 ppm Cl2

Page 22: Pediatric Department University of Verona Italy Giorgio Piacentini

Chlorine-induced Injury to the Airways in MiceMartin: AJRCCM 2003; 168:568–574

Exposure to Cl2 gas

occupational asthma

?induction of

airway inflammationand AHR

by oxidative damage

24 hours after a 5-minute exposure to 100 200 400 800

MCH assessed

ppm Cl2

2 and 7 days after 400 ppm Cl2

dose-dependent Increases in RRS that were comparable in all treatment groups At low doses of MCh, but at high doses (80 and 160 g/kg) theresponses were significantly higher after 400 and 800 ppm

Page 23: Pediatric Department University of Verona Italy Giorgio Piacentini

Chlorine-induced Injury to the Airways in MiceMartin: AJRCCM 2003; 168:568–574

Exposure to Cl2 gas

occupational asthma

?induction of

airway inflammationand AHR

by oxidative damage

24 hours after a 5-minute exposure to 100 200 400 800

MCH assessed

ppm Cl2

2 and 7 days after 400 ppm Cl2

dose-dependent Increases in RRS that were comparable in all treatment groups At low doses of MCh, but at high doses (80 and 160 g/kg) theresponses were significantly higher after 400 and 800 ppm

Page 24: Pediatric Department University of Verona Italy Giorgio Piacentini

Chlorine-induced Injury to the Airways in MiceMartin: AJRCCM 2003; 168:568–574

Exposure to Cl2 gas

occupational asthma

?induction of

airway inflammationand AHR

by oxidative damage

24 hours after a 5-minute exposure to 100 200 400 800

MCH assessed

ppm Cl2

2 and 7 days after 400 ppm Cl2

Page 25: Pediatric Department University of Verona Italy Giorgio Piacentini

Chlorine-induced Injury to the Airways in MiceMartin: AJRCCM 2003; 168:568–574

Exposure to Cl2 gas

occupational asthma

?induction of

airway inflammationand AHR

by oxidative damage

24 hours after a 5-minute exposure to 100 200 400 800

MCH assessed

ppm Cl2

2 and 7 days after 400 ppm Cl2

There was a significant increase in responsiveness both for RRS and ERS

Page 26: Pediatric Department University of Verona Italy Giorgio Piacentini

Chlorine-induced Injury to the Airways in MiceMartin: AJRCCM 2003; 168:568–574

Exposure to Cl2 gas

occupational asthma

?induction of

airway inflammationand AHR

by oxidative damage

24 hours after a 5-minute exposure to 100 200 400 800

MCH assessed

ppm Cl2

2 and 7 days after 400 ppm Cl2

There was evidence in two independentexperiments of an increase in iNOS expression after Chlorine exposure, but there was no clear dose dependence of expression

Page 27: Pediatric Department University of Verona Italy Giorgio Piacentini

Chlorine-induced Injury to the Airways in MiceMartin: AJRCCM 2003; 168:568–574

Exposure to Cl2 gas

occupational asthma

?induction of

airway inflammationand AHR

by oxidative damage

24 hours after a 5-minute exposure to 100 200 400 800

MCH assessed

ppm Cl2

2 and 7 days after 400 ppm Cl2

There was a smallamount of bronchial epithelial staining with an anti–3-NT antibody revealed by Fast Red in mice exposed to 100 ppm chlorine for 5 minutes…

Page 28: Pediatric Department University of Verona Italy Giorgio Piacentini

Chlorine-induced Injury to the Airways in MiceMartin: AJRCCM 2003; 168:568–574

Exposure to Cl2 gas

occupational asthma

?induction of

airway inflammationand AHR

by oxidative damage

24 hours after a 5-minute exposure to 100 200 400 800

MCH assessed

ppm Cl2

2 and 7 days after 400 ppm Cl2

…and substantially morein mice exposed to 800 ppm chlorine

Page 29: Pediatric Department University of Verona Italy Giorgio Piacentini

Chlorine-induced Injury to the Airways in MiceMartin: AJRCCM 2003; 168:568–574

Exposure to Cl2 gas

occupational asthma

?induction of

airway inflammationand AHR

by oxidative damage

24 hours after a 5-minute exposure to 100 200 400 800

MCH assessed

ppm Cl2

2 and 7 days after 400 ppm Cl2

…and substantially morein mice exposed to 800 ppm chlorine

The staining was largely confined to the apical border of the epithelial cell

Page 30: Pediatric Department University of Verona Italy Giorgio Piacentini

Chlorine-induced Injury to the Airways in MiceMartin: AJRCCM 2003; 168:568–574

Exposure to Cl2 gas

occupational asthma

?induction of

airway inflammationand AHR

by oxidative damage

24 hours after a 5-minute exposure to 100 200 400 800

MCH assessed

ppm Cl2

2 and 7 days after 400 ppm Cl2

The staining was largely confined to the apical border of the epithelial cell

Chlorine exposure causes functional and pathological changes in the airways associated with oxidative stress.

Inducible nitric oxide synthase is involved in the induction of changes in responsiveness to methacholine

Page 31: Pediatric Department University of Verona Italy Giorgio Piacentini

Schematic representation of asthma pathophysiology

Holgate: Trends in immunology 2007, 28: 248

Page 32: Pediatric Department University of Verona Italy Giorgio Piacentini

Changes in serum pneumoproteins caused by shortterm exposures to nitrogen trichloride in indoor chlorinated swimming pools

Carbonnelle: Biomarkers 2002; 7:464

Effects of NCl3 on the pulmonary epithelium of pool attendees by measuring the leakage into serum of three pneumoproteins:

the alveolar surfactant associatedproteins A and B (SP-A and SP-B)

the bronchiolar 16 kDa Clara cellprotein (CC16).

29 recreational swimmers (16 children and 13 adults)

before and after attending a chlorinated pool

Page 33: Pediatric Department University of Verona Italy Giorgio Piacentini

Changes in serum pneumoproteins caused by shortterm exposures to nitrogen trichloride in indoor chlorinated swimming pools

Carbonnelle: Biomarkers 2002; 7:464

Effects of NCl3 on the pulmonary epithelium of pool attendees by measuring the leakage into serum of three pneumoproteins:

the alveolar surfactant associatedproteins A and B (SP-A and SP-B)

the bronchiolar 16 kDa Clara cellprotein (CC16).

29 recreational swimmers (16 children and 13 adults)

before and after attending a chlorinated pool

Short-term exposure to NCl3 in the air of indoor chlorinated pools can produce permeability changes of the deep lung that are undetected by classical lung function tests.

Page 34: Pediatric Department University of Verona Italy Giorgio Piacentini

Respiratory health and baby swimmingBernard: Arch Dis Child 2006;91:620

Possible effects ofexposing babies to the volatile chlorinationproducts of indoor poolsthat have been found to affect the lung epithelium and to increase asthma risk

? –

8

10.4

Serum CC16g/l)

p=0.01

Asthma (%)

23.3

11.1

p=0.025

RecurrentBronchitis (%)

60.5

36.9

p=0.006

341 schoolchildrenaged 10–13 years

Swimming baby (n=43)

Other children (n=298)

a loss of the Clara cells lining the terminal airways

Page 35: Pediatric Department University of Verona Italy Giorgio Piacentini

Infant Swimming Practice, Pulmonary Epithelium Integrity, and the Risk of Allergic and Respiratory Diseases Later in Childhood

Bernard: Pediatrics 2007; 119:1095

impact of infant swimming practice on allergic status and respiratory health later in childhood

?341 schoolchildrenaged 10–13 years

Swimming baby (n=43)

Other children (n=298)14

8.7

FeNO (ppb)

ns

Allergy to aeroall. (%)

30.2 31.9

ns

Allergy to HDM (%)

1419.1

ns

Page 36: Pediatric Department University of Verona Italy Giorgio Piacentini

Infant Swimming Practice, Pulmonary Epithelium Integrity, and the Risk of Allergic and Respiratory Diseases Later in Childhood

Bernard: Pediatrics 2007; 119:1095

impact of infant swimming practice on allergic status and respiratory health later in childhood

?341 schoolchildrenaged 10–13 years

Swimming baby (n=43)

Other children (n=298) 10.2 8.9

Wheezing (%)

ns

Chest tightness

(%)

14

4.4

p=0.03

EIB (%)

9.33.7

p<0.05

60.5

36.9

Recurrent Bronchitis (%)

P=0.006

Page 37: Pediatric Department University of Verona Italy Giorgio Piacentini

Infant Swimming Practice, Pulmonary Epithelium Integrity, and the Risk of Allergic and Respiratory Diseases Later in Childhood

Bernard: Pediatrics 2007; 119:1095

impact of infant swimming practice on allergic status and respiratory health later in childhood?341 schoolchildrenaged 10–13 years

Swimming baby (n=43)

Other children (n=298)

asthma and recurrent bronchitis alone had no influence on the serum levels of pneumoproteins.

Highly significant decrease of serum CC16 associated with infant swimming activity (P .001).

The levels of serum CC16 werethe lowest inthe infant swimming group who were asthmatic or with recurrent bronchitis.

Page 38: Pediatric Department University of Verona Italy Giorgio Piacentini

Swimming baby (n=43)

Infant Swimming Practice, Pulmonary Epithelium Integrity, and the Risk of Allergic and Respiratory Diseases Later in Childhood

Bernard: Pediatrics 2007; 119:1095

impact of infant swimming practice on allergic status and respiratory health later in childhood?

Other children (n=298)

Swimming baby practice in chlorinated indoor pools can be associated with distal airways alterations predisposing children to the development of asthma and recurrent bronchitis

Caution before regularly taking babies to poorly ventilated indoor pools where there is a strong chlorine smell

Page 39: Pediatric Department University of Verona Italy Giorgio Piacentini

INFANT SWIMMING MAY RISK FUTURE RESPIRATORY HEALTH

The American Academy of Pediatrics (AAP) has long recommended against infant swimming lessons due to the false sense of safety that this practice gives

regarding the risk of drowning.

Now a new study may add another reason to avoid infant swim lessons. “Infant Swimming Practice, Pulmonary Epithelium Integrity, and Risk of Allergic and

Respiratory Diseases Later in Childhood,” examined the role indoor chlorinated pools play in the development of asthma and reduced lung function.

The study, conducted in Belgium, found that trichloramine – a chlorine byproduct that gives indoor pools their distinctive “chlorine” smell – is one of the most

concentrated air pollutants to which children of developed countries are regularly exposed.

The study asserts that this pollutant along with other aerosolized chlorine-based oxidants can be associated with airway changes that predispose children to

asthma and recurrent bronchitis later in childhood.

They encourage more study and possible regulation of the air quality in the indoor pool environment

                                                                                

                                  

Page 40: Pediatric Department University of Verona Italy Giorgio Piacentini

Criticism of Infant Swimming Practice Is Political, Not Scientific

Reich: Pediatrics 2007;120:926

Bernard et al did not state that infant swimming causes asthma but, rather, that infant swimming in indoor pools, along with other factors, is associated with airway changes that may predispose children to asthma.

The conclusion was qualified because the study was too small to draw a conclusion.

Certainly, there was no increase in hospitalizations, emergency department visits, or mortality.

There is a definitive need to assess the effects of chlorination products on the respiratory

tract of very young children

Page 41: Pediatric Department University of Verona Italy Giorgio Piacentini

Swimming pool attendance and exhaled nitric oxide in children

Carraro: JACI 2006;118:958

100 hundred children regularly attending a swimming pool for at least 6 months and for at least1 hour a week

141 not regularly attending a swimming pool

Which kind of airway inflammation?

Page 42: Pediatric Department University of Verona Italy Giorgio Piacentini

Swimming pool attendance and exhaled nitric oxide in children

Carraro: JACI 2006;118:958

100 hundred children regularly attending a swimming pool for at least 6 months and for at least1 hour a week

141 not regularly attending a swimming pool FENO level, an exhaled biomarker

of eosinophilic airway inflammation,is similar in children who regularly attend a swimming pool and in those who do not.

Which kind of airway inflammation?

Page 43: Pediatric Department University of Verona Italy Giorgio Piacentini

Swimming pool attendance and exhaled nitric oxide in children

Carraro: JACI 2006;118:958

100 hundred children regularly attending a swimming pool for at least 6 months and for at least1 hour a week

141 not regularly attending a swimming pool

Children regularly attending indoor swimming pools for 1 to 2 hours a week do not have increased FENO levels, suggesting that intermittent exposure to chlorine derivatives does not induce eosinophilic airway inflammation. Further studies might be useful to evaluate whether such exposure can induce any other inflammatory responses in the airways of recreational swimmers

Which kind of airway inflammation?

Page 44: Pediatric Department University of Verona Italy Giorgio Piacentini

Airway inflammation in elite swimmersPiacentini: JACI 2007:119:1559

5 elite athletes of the Italian NationalSwimming Team

5 age-matched subjects not performing swimming regularly

FeNO

EBC for LTB4 assay

15

41.9

12

5.5

p=0.033

FeNO(ppb)

LTB4(pg/ml)

n.s.

Which kind of airway inflammation?

Page 45: Pediatric Department University of Verona Italy Giorgio Piacentini

Airway inflammation in elite swimmersPiacentini: JACI 2007:119:1559

5 elite athletes of the Italian NationalSwimming Team

5 age-matched subjects not performing swimming regularly

FeNO

EBC for LTB4 assay

15

41.9

12

5.5

p=0.033

FeNO(ppb)

LTB4(pg/ml)

Longitudinal Monitoring of Lung Injury in Childrenafter Acute Chlorine Exposure in a Swimming Pool

Bonetto: AJRCCM 2006; 174:545

Significantlyhigher serum CC16

Page 46: Pediatric Department University of Verona Italy Giorgio Piacentini

Airway inflammation in elite swimmersPiacentini: JACI 2007:119:1559

5 elite athletes of the Italian NationalSwimming Team

5 age-matched subjects not performing swimming regularly

FeNO

EBC for LTB4 assay

15

41.9

12

5.5

p=0.033

FeNO(ppb)

LTB4(pg/ml)

Longitudinal Monitoring of Lung Injury in Childrenafter Acute Chlorine Exposure in a Swimming Pool

Bonetto: AJRCCM 2006; 174:545

Epithelial Lung Injury?

Page 47: Pediatric Department University of Verona Italy Giorgio Piacentini

Airway inflammation in elite swimmersPiacentini: JACI 2007:119:1559

5 elite athletes of the Italian NationalSwimming Team

5 age-matched subjects not performing swimming regularly

FeNO

EBC for LTB4 assay

15

41.9

12

5.5

p=0.033

FeNO(ppb)

LTB4(pg/ml)

Longitudinal Monitoring of Lung Injury in Childrenafter Acute Chlorine Exposure in a Swimming Pool

Bonetto: AJRCCM 2006; 174:545

Page 48: Pediatric Department University of Verona Italy Giorgio Piacentini

Airway inflammation in elite swimmersPiacentini: JACI 2007:119:1559

5 elite athletes of the Italian NationalSwimming Team

5 age-matched subjects not performing swimming regularly

FeNO

EBC for LTB4 assay

15

41.9

12

5.5

p=0.033

FeNO(ppb)

LTB4(pg/ml)

Longitudinal Monitoring of Lung Injury in Childrenafter Acute Chlorine Exposure in a Swimming Pool

Bonetto: AJRCCM 2006; 174:545

Substantial lung function impairment associated with biochemical exhaled breath alterations, represented mainly by an increase in LTB4 and a reduction in FeNO.

Although lung function and exhaled NO improved within a few weeks, the increased levels of exhaled LTB4 persisted for several months, suggesting persistent neutrophilic inflammation despite the lack of respiratory symptoms and the normalization of routine lung function test findings.

Page 49: Pediatric Department University of Verona Italy Giorgio Piacentini

Airway inflammation in elite swimmersPiacentini: JACI 2007:119:1559

5 elite athletes of the Italian NationalSwimming Team

5 age-matched subjects not performing swimming regularly

FeNO

EBC for LTB4 assay

15

41.9

12

5.5

p=0.033

FeNO(ppb)

LTB4(pg/ml)

A potential role of chronic exposure to a chlorine-rich atmosphere can favour the development of airway neutrophilic inflammation in elite swimmers.

Page 50: Pediatric Department University of Verona Italy Giorgio Piacentini

Health risks of early swimming pool attendanceSchoefer: Int J Hyg Environ Health in press

Relationship betweenearly swimming pool attendance, especially baby swimming, and early infections and allergic diseases

?

2192 children

6-year follow-upprospective birth cohort study

2.1

4.62.6

4.1 4.75.8

1st year baby

swimming

Asthma (%)

Rhinitis (%)

1st year occasionally

Between ages

1 and 3

14

7.3

Later or

never

Age of first pool attendance

Doctor diagnosed after the 1st year of life up to age 6

Page 51: Pediatric Department University of Verona Italy Giorgio Piacentini

Health risks of early swimming pool attendanceSchoefer: Int J Hyg Environ Health in press

Relationship betweenearly swimming pool attendance, especially baby swimming, and early infections and allergic diseases

?

2192 children

6-year follow-upprospective birth cohort study

2.1

4.62.6

4.1 4.75.8

1st year baby

swimming

Asthma (%)

Rhinitis (%)

1st year occasionally

Between ages

1 and 3

14

7.3

Later or

never

Age of first pool attendance

Doctor diagnosed after the 1st year of life up to age 6

In terms of developing atopic diseasesthere is no verifiable detrimental effect of

early swimming.

Page 52: Pediatric Department University of Verona Italy Giorgio Piacentini

Health risks of early swimming pool attendanceSchoefer: Int J Hyg Environ Health in press

Relationship betweenearly swimming pool attendance, especially baby swimming, and early infections and allergic diseases

?

2192 children

6-year follow-upprospective birth cohort study

2.1

4.62.6

4.1 4.75.8

1st year baby

swimming

Asthma (%)

Rhinitis (%)

1st year occasionally

Between ages

1 and 3

14

7.3

Later or

never

Age of first pool attendance

Doctor diagnosed after the 1st year of life up to age 6

One important difference between Belgium andGermany is the difference of maximum recommended levels for combined chlorine. In Belgium the maximum of 2 ppm, the level is 10 times higher than German standards, where limits of water concentrations of 0.3–0.6 mg/l for free chlorine, 0.2 mg/l for bound chlorine have to be maintained

Page 53: Pediatric Department University of Verona Italy Giorgio Piacentini

Swimming and Persons with Mild Persistant Asthma

Aranđelović:TheScientificWorldJournal 2007; 1182–1188

effect of recreational swimming on lung function and bronchial hyperresponsiveness (BHR) in patients with mild persistent asthma

?65 mild persistent asthmatics

group A (n = 45): swimming (twice a week on a 1-h basis for the following 6 months)

group B (n = 20): control

4.0 –

3.8 –

3.6 –

3.4 –

3.2 –

0

3.55

3.29

3.65

3.33

p<0.01

p<0.05

T0 T1 T0 T1

FEV1 (L/min)

Page 54: Pediatric Department University of Verona Italy Giorgio Piacentini

Swimming and Persons with Mild Persistant Asthma

Aranđelović:TheScientificWorldJournal 2007; 1182–1188

effect of recreational swimming on lung function and bronchial hyperresponsiveness (BHR) in patients with mild persistent asthma

?65 mild persistent asthmatics

group A (n = 45): swimming (twice a week on a 1-h basis for the following 6 months)

group B (n = 20): control

FEV1 (L/min)

4.0 –

3.8 –

3.6 –

3.4 –

3.2 –

0

3.55

3.29

3.65

3.33

T0 T1 T0 T1

p<0.001

Page 55: Pediatric Department University of Verona Italy Giorgio Piacentini

Swimming and Persons with Mild Persistant Asthma

Aranđelović:TheScientificWorldJournal 2007; 1182–1188

effect of recreational swimming on lung function and bronchial hyperresponsiveness (BHR) in patients with mild persistent asthma

?65 mild persistent asthmatics

group A (n = 45): swimming (twice a week on a 1-h basis for the following 6 months)

group B (n = 20): control

Hist. PD20

3.0 –

2.5 –

2.0 –

1.5 –

1.0 –

0

0.58 0.61

2.011.75

p < 0.001

p < 0.05

T0 T1 T0 T1

Page 56: Pediatric Department University of Verona Italy Giorgio Piacentini

Swimming and Persons with Mild Persistant Asthma

Aranđelović:TheScientificWorldJournal 2007; 1182–1188

effect of recreational swimming on lung function and bronchial hyperresponsiveness (BHR) in patients with mild persistent asthma

?65 mild persistent asthmatics

group A (n = 45): swimming (twice a week on a 1-h basis for the following 6 months)

group B (n = 20): control

Hist. PD20

3.0 –

2.5 –

2.0 –

1.5 –

1.0 –

0

0.58 0.61

2.011.75

p<0.001

T0 T1 T0 T1

Page 57: Pediatric Department University of Verona Italy Giorgio Piacentini

Swimming and Persons with Mild Persistant Asthma

Aranđelović:TheScientificWorldJournal 2007; 1182–1188

effect of recreational swimming on lung function and bronchial hyperresponsiveness (BHR) in patients with mild persistent asthma

?65 mild persistent asthmatics

group A (n = 45): swimming (twice a week on a 1-h basis for the following 6 months)

group B (n = 20): control

Hist. PD20

3.0 –

2.5 –

2.0 –

1.5 –

1.0 –

0

0.58 0.61

2.011.75

p<0.001 Engagement of patients with mild, persistent asthma in recreational swimming in nonchlorinated pools, combined with regular medical treatment and education, leads to better improvement of their parameters of lung function and also to a more significant decrease of their BHR compared to patients treated with traditional medicine

Page 58: Pediatric Department University of Verona Italy Giorgio Piacentini

Pediatric DepartmentUniversity of Verona Italy

Giorgio Piacentini